Incident Report Form
Name of Person Completing Form (First name and Initial of Last name only)
Name of Client Involved
Email Address
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident Started
Hour Minutes
AM
PM
AM/PM Option
Time incident ended
Hour Minutes
AM
PM
AM/PM Option
Type of Incident
Client Behaviour
Near miss(Something nearly happened)
Illness
Medication Incident
Suspect law broken
Breach of Policy
Property Damage/loss
Injury
Night Disturbance
Location of Incident
Client's Home
Community Access
Office
Support Worker's Car
Other
Location of incident
Any restrictive practice used to manage behaviour
*
seclusion (This is when participant is in a room alone and not allowed to leave.)
Chemical Restraint (This is when participant is given medicine to change or stop a behaviour)
Mechanical Restraint (This is when a device or equipment is used to stop a behaviour.)
Physical Restraint (This is when someone stops a participant from moving a part of their body to stop a behaviour.)
Environmental Restraint (This is when a participant is stopped from having certain things, e.g ,locked fridge, locked doors, locked items)
None of the above
Other
What was happening before incident
What happened during incident and how did it end?
Detail how Restrictive practice(RP) was used and How long was it used for? (Write N/A if not applicable)
*
What happened after incident
Have you discussed Incident with anyone? Incidents must be discussed with your Team Leader and/or the On Call Manager. Please provide details of the discussion
FOLLOW UP ACTION: TO BE COMPLETED BY MANAGER
IS THIS A REPORTABLE INCIDENT?( TO BE COMPLETED BY MANAGER)
Yes
No
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